Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Note:
Reason for Encounter
Briefly state the reason for this encounter. This could be:
New or worsening rough, scaly patches on sun-exposed skin.
Follow-up visit for a patient with known actinic keratosis (AK).
Evaluation and treatment of a suspected AK lesion.
History of Present Illness (HPI)
Lesion Characteristics:
Describe the number, location, size, color, and appearance of the suspicious lesions.
Mention any associated symptoms like itching, burning, or bleeding.
Sun Exposure:
Inquire about the patient’s history of sun exposure (occupational, recreational) and sun protection habits (sunscreen use).
Past Medical History (PMHx):
Briefly mention any relevant past medical history, such as:
Previous skin cancers
Immunosuppression (medications or conditions)
Medications: List all current medications the patient is taking.
Social History (SHx)
Include relevant social history that may be pertinent, such as:
Smoking history
Family History
Inquire about a family history of skin cancer.
Physical Examination
Skin:
Focus on sun-exposed areas (face, scalp, ears, neck, arms, hands, legs).
Describe the location, size, color, and surface texture of the suspicious lesions.
Assessment
Summarize the key findings from the history and physical examination.
Formulate a differential diagnosis, considering AK and other possibilities like seborrheic keratosis, psoriasis, or warts.
Plan
Outline the next steps in the patient’s management. This may include:
Diagnostic Tests:
In some cases, a skin biopsy may be needed to confirm the diagnosis, especially if the lesion is atypical.
Treatment Options: (Depending on lesion characteristics and patient factors)
Cryotherapy: Freezing the lesion with liquid nitrogen.
Topical Therapies: Creams or ointments containing imiquimod, 5-fluorouracil, or diclofenac.
Surgical Excision: Removal of the lesion with scalpel, shave biopsy, or curettage.
Photodynamic Therapy (PDT): A light-based therapy used for certain AKs.
Sun Protection Education:
Emphasize the importance of sun protection measures (sunscreen, sun-protective clothing, seeking shade) to prevent new lesions.
Follow-up: Schedule a follow-up visit to monitor response to treatment and assess for new lesions.
Additional Considerations
Adapt this template based on the specific situation (initial evaluation, follow-up visit).
Use clear and concise language while maintaining medical accuracy.
Document the specific treatment chosen and planned course of action.
Consider referring the patient to a dermatologist for complex cases or extensive lesions.
This template provides a framework for documenting progress notes for patients with suspected or known actinic keratosis. Remember to tailor it to your specific workflow and facility’s documentation standards.